Application

Please print and mail this form

CITY OF STOUGHTON

LANDMARKS COMMISSION

CERTIFICATE OF APPROPRIATENESS APPLICATION FORM

1. NAME OF PROPERTY: ___________________________________________________

Address of Property: ____________________________________________________

Name of historic district in which property is located _________________________

____________________________________________________________________

2. NAME AND ADDRESS OF OWNER

Name: ______________________________________________________________

Street address: ________________________________________________________

City: ____________________________ State: _______ Zip: ___________

Telephone Number (during Day) Area Code: _______________________________

Applicant (if different from owner): ______________________________________

Telephone number (during day) Area Code: ________________________________

3. ATTACHMENTS: The following information is enclosed:

_________ Exterior photographs

_________ Sketches, elevation drawings and/or annotated photographs

_________ Floor plans

_________ Site plan showing relative location of adjoining structures, if within a district.

_________ Specifications

_________ Other (explain) ________________________________________________

4. Signature of Applicant

______________________________________________ Date: ________________

RETURN TO: Landmarks Commission, City Clerk's Office, Stoughton City Hall, Stoughton, WI 53589

DESCRIPTION OF PROJECT

Architectural feature: ____________________________________________________________________________

__________________________________________________________________________________

Approximate date of feature: ____________________________________________________________

Describe existing feature: ______________________________________________________________

___________________________________________________________________________________

Describe proposed work, materials to be used and impact of existing feature:

___________________________________________________________________________________

Photo No._______________________ Drawing No. ____________________________________